Health inspection·December 18, 2025

F 0677 Level of Harm - Actual harm Residents Affected - Few the administrator and has been told not to text his personal phone. FM A stated 02/18/25 nurses refused to change Resident #1 when she asked just before 11:00am saying she needed to wait till after lunch to be served. FM A stated on 03/18/25 at about 2:20am Resident #1 had called saying she asked to be changed, and a nurse or CNA said, it hasn't even been 2 hours and told her No. And turn the call light off and leave. An hour later 2 more nurses came in asking what's wrong she said she needed to be changed, and they said gimme a minute, turned the light off, and left and an hour after that she called saying she had been sitting in cold piss for over 3 hours. FM A stated on 04/16/25 Resident #1 called at 10:40pm saying she can't get anyone in her room to change her and that she had been asking since 6:30pm and that when she calls from her cell phone a nursing staff member picks up phone and says, ok and hangs up. FM A stated [DATE], Resident #1 called him at 3:10am crying cause she couldn't get changed saying she hadn't been changed since 9:00pm. I called the facility and was placed on hold with station #2 for 30 minutes and never got ahold of anyone. FM A stated Resident #1 called again at 3:50am during this call and someone finally came into the room to change her. FM stated Resident #1 should not be sitting in a soaked diaper with bedsores for hours. During an interview on 12/17/25 at 10:25am with Resident #1 she stated she has had a lot of issues with nursing staff, specifically on the 3rd shift, who refuse to answer her call light and give her incontinent care, by changing her diaper leaving her in urine and sometimes feces for hours. She stated the issues with her ill treatment by nursing staff began in January 2025 and has continued till this date. Resident #1 stated she's left in bed soaked because the third shift will not answer her calls or if they come into her room they berate her, scream at her and refuse to give her care [Resident #1 was unable to provide specific staff names, dates and details of these incidents]. Resident #1 stated staff will come in the room, then just turn off her call light or more often than not. Resident #1 stated she spoke with CNA A that her call light was not being answered which was mostly on 3rd shift. Resident #1 stated she felt neglected, belittled, and ashamed. Resident #1 stated FM A had specific times and days the issues started because she called FM A on these days and he documented this. Resident #1 stated talking to supervisors, management has gotten her and FM A nowhere.During an interview on 12/17/25 at 10:40am with Resident #2, who is Resident #1's roommate, she stated she has witnessed the verbal abuse (i.e., what do you want now? You've already changed so you will just have to wait. Can't wait until you leave. [Resident #2 was unable to provide staff names, dates or other specific details of these details]) from the 3rd shift staff and nurse regarding Resident #1. Resident #2 stated she doesn't have any issues and when she pushes her call button night shift staff responds to her, but they don't respond to Resident #1. She stated Resident #1 has been in a lot of pain and pushed her button and nursing very seldom respond. Resident #2 stated Resident #1 was in a lot of pain one night (could not remember the night or CNA staff name), so she pushed her own call button to get assistance for Resident #1. When CNA staff arrived to her room, Resident #2 told the CNA that she pushed her button by accident; however, Resident #1 has been pushing her button for a while and needed assistance because she was in pain. She stated the CNA just turned both call lights off and left the room without acknowledging Resident #1. Resident #2 was unable to remember the exact day or the CNA. Resident #2 stated she has heard LVN A and CNA's tell Resident #1 they didn't like her nor will they change her. Resident #2 stated Resident #1 often has had to wait until shift change and first shift nursing staff to change Resident #1 because the night nurse or CNA's refuse to do it or answer her call light.During an interview on 12/17/25 at 1:30pm with CNA A she stated she was familiar with Resident #1 and she has been told night shift nursing staff were verbally abusive to her [CNA A was unable to give nursing staff names or dates]. She stated she has also been told that the 2-10 shift and night (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Actual harm Residents Affected - Few shift hardly answers Resident #1's call light. CNA A stated she gets a lot of complaints from Station #2 residents regarding the lack of care from 2-10 and overnight shift. She stated she just passed the information on to the charge nurse on that day and in the past passed on similar concerns to ADON A.During an interview on 12/18/25 at 5:28am with LVN F she stated all residents needed to be checked on every two hours even if no call light is on. LVN F stated when she arrived for her shift (Night) she does rounds to see all residents and take nursing reports from the outgoing (second shift) nurse. LVN F stated Resident#1 is not difficult, but difficult within reason, which indicates that Resident #1 feels things aren't getting done her way she becomes irritated with a snappy attitude, but she is not aggressive and does not use profanity. LVN F stated if Resident #1 doesn't get along with someone or feels the nurse was rude to her, she will refuse care. She stated there was a CNA who felt Resident #1 was rude to her and would not provide care; however, LVN F stated she removed that can and replaced her with another one. When LVN F was asked if she has been unprofessional with Resident #1, she responded, she wants to say no she hasn't been unprofessional with Resident #1; however, there were interactions with Resident#1. LVN F stated Resident #1 never verbalized to her that she was having problems with other nursing staff other than another aide that Resident #1 said she was rude, which occurred 2-3 weeks. She stated she spoke with both, Resident# 1 and CNA. LVN F stated Resident 1 told her that she and the CNA didn't get along but didn't tell her specific incidents. LVN F stated she did not report the incident to anyone but feels like she should have said something management because the situation could have accelerated. LVN F stated Resident #1 is cognate and knows what she's talking about. LVN F stated she spoke with FM A regarding Resident # 1, needing to be changed one night. LVN F stated she asked Resident #1 had she been changed and Resident #1 stated she had not. At this time, she asked the CNA to change her. LVN F stated this has occurred on a couple occasions. During an Interview on 12/18/25 with Administrator he stated during a care Resident #1 mentioned her shirts were missing and the shirts were purchased by the facility. Administrator stated any issues or concerns Resident #1 FM A has his personal number. Administrator stated Resident #1 and FM A has not mentioned Resident #1 was being mistreated. Administrator stated FM A was last seen on Thanksgiving. Administrator denied ever telling FM A not to call his personal cell. Administrator denied FM A told him that Resident #1 was not being changed by nursing staff. Administrator stated Resident #1 has never told him she has concerns with any incontinent care being given by nursing staff. During an interview on 12/18/25 at 10:27am with ADON A she stated she has received complaints about staff not answering call lights and she has completed in-service training with staff regarding this issue. She stated she has not received any complaints for a specific staff member not answering call lights. ADON A stated she expects nursing staff members to be on time for work, make their rounds by seeing each resident, going into rooms to make sure residents' needs are met or if they needed anything, and to ensure all residents' call lights were in reach. She stated she usually see Resident #1 frequently or a couple of times a week when doing her rounds, but Resident #1 has never had any complaints regarding her care, nor had she told her nursing staff was rough with her. ADON A stated she has spoken with FM A regarding Resident #1's medications, but never regarding care. ADON A stated FM A has not called the facility in a while.During a telephone interview on 12/18/25 at 12:55pm with LVN E she stated she was assigned to station 2 and familiar with Resident #1. She stated she only provides nursing treatment, and she does not change residents. LVN E stated one CNA cannot change or transfer Resident #1 because she is overweight. LVN E stated two CNA's will change Resident #1 to avoid Resident #1 from falling on the floor. LVN E stated that she spoke with FM A on one occasion and wanted someone to check Resident #1's blood pressure. She stated she never knew that Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete #1 was having issues. LVN E stated CNA's are expected to do rounds every two hours or more to check on residents as needed. Record Review of Resident Rights policy dated February 2021 revealed, Employee show treat all residents with kindness, respect, and dignity.1. federal and state laws that guarantee certain basic rights to all residents of this facility. These rights include the residents right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;f. Communications with access to people and services, both inside and outside the facility;h. Be supported by the facility in exercising his or her rights. Event ID: Facility ID: 675233 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 34 residents (Residents #10, #11, and #12,) reviewed for accidents and supervision. 1. The facility failed to ensure Residents #10, #11, and #12 were supervised while smoking on 12/18/2025 at 5:09 AM. 2. The facility failed to ensure Residents #10, #11, and #12 smoking supplies were stored securely when they were observed smoking unsupervised on 12/18/2025 at 5:09AM. These deficient practices could place residents at risk of burns causing injury or harm. Findings include: Record review of a Face Sheet for Resident #10 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Unspecified Dementia (a severe decline in mental abilities, like memory, thinking, and reasoning, significant enough to disrupt daily life and activities), Mild protein-malnutrition (involves subtle but significant nutrient deficiency), hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), bipolar disorder (a mental health condition causing extreme mood swings from emotional highs to lows, affecting energy, judgement, and behavior), hypertensive heart disease (damage to the heart from long-term high blood pressure (hypertension) causing the heart muscle to thicken as it works harder), cognitive communication deficit, schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with those of a mood disorder), and major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of internet in activities). Record review of Resident#10's Quarterly MDS dated [DATE] revealed a BIMS score of 08 which indicated a cognition level of moderately impaired. Record review of Resident#10's undated care plan revealed a focus that Resident#10 was a tobacco smoker and is at risk for injury, encourage resident to wear a smoke apron. Interventions stated instruct encourage resident to wear a smoke apron while smoking, keep smoking material at nurses' station, review smoking policy w/ resident annually and PRN with concerns. Record review of a Face Sheet for Resident #11 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Hemiplegia and hemiparesis following cerebral infarction affecting right non dominant side (damage to the brain's left hemisphere, impacting movement, coordination, balance, and potentially cognition), Atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in your hearts arteries that isn't causing chest pain yet), Heart failure, presence of cardiac pace maker, hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), hypokalemia (having low levels of potassium in your blood), Contracture, right hand. Record review of Resident#11's Quarterly MDS dated [DATE] revealed a BIMS score of 07 which indicated a cognition level that was severely impaired. Record review of Resident#11's undated care plan revealed a focus that Resident#11 was a tobacco smoker and is at risk for injury' required to wear a smoke apron related to contractures; refuses to wear a smoke apron. Interventions stated keeping smoking material at nurses' station; require supervision while smoking, required to wear a smoke apron. The care plan revealed another focus of . Smoking on patio for social interaction, resident requires direction assistance to attend; resident appears to be pre-occupied with smoking; episodes of not following the smoking policy. The residents' goal revealed resident will remain compliant with smoking policy and injury free. Interventions stated post activity calendar in room where resident can see, Remind/invite resident to scheduled activities of choice/interest; encourage resident to wear a smoke apron. Record review of a Face Sheet for Resident #12 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus, hereditary and idiopathic neuropathy, unspecified (refers to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some peripheral nerve damage where the cause isn't definitively genetic), hyperlipidemia (a condition with too many fats in the blood, often call high cholesterol), Unspecified Dementia (a severe decline in mental abilities, like memory, thinking, and reasoning, significant enough to disrupt daily life and activities). Record review of Resident#12's Quarterly MDS dated [DATE] revealed a BIMS score of 04 which indicated a cognition level that was severely impaired. Record review of Resident#12's undated care plan revealed a focus that Resident#12 was a tobacco smoker and is at risk for injury, encourage the resident to wear a smoke apron. Interventions stated encourage residents to wear a smoking apron while smoking. Keep smoking material at nurse's station. Observation on 12/18/25 at 5:09 AM of 3 (Resident #10, #11, and #12) residents smoking unsupervised in the smoking area. In an interview/observation on 12/18/25 at 5:10 AM; Resident #10 was observed smoking in the smoking area unsupervised with no apron on. Resident #10 stated the residents have smoke times but reported that they sometimes come out to smoke during this time (5 AM) on their own. She stated the smoke times did not start until 9am but reported that they sometimes wanted to smoke before then. She stated the staff keeps their smoking supplies and provides them when it is time to smoke. She stated she had gotten a cigarette from another resident but did not provide the name of the resident who provided her with the cigarette. Resident #10 was observed with no burn marks on her clothing or skin. In an interview/observation on 12/18/25 at 5:10 AM; Resident #11 was observed in the smoking area of the facility unsupervised. She stated that in the mornings she and others come out and smoke and there are never any staff members because it's not smoking times. She stated cigarettes and lighters are kept at the nursing station #1in a box. She stated no one ever told her that a staff member needed to be out in the smoking area with residents. Resident #11 was not observed with any burn marks on her skin or clothing. In an interview/observation on 12/18/25 at 5:15AM; Resident #12 was observed in the smoking area, smoking a cigarette unsupervised without an apron on. Surveyor attempted to interview the resident, but he stated, I don't have anything to say to you and proceeded to put his cigarette out and entered the building of the facility. In an interview on 12/18/25 at 5:25 AM with CNA- B; She stated the residents have smoking times, but they go out and smoke on their own at night. She stated the residents are not supposed to smoke on their own, but they do it anyway. She stated the residents have their own smoking supplies, she stated they are not supposed to keep their own smoking supplies, but they keep them anyway. She stated the smoking supplies are kept at station #1 nursing station. She stated the residents did not smoking times during night shift. She stated the administration staff were knowledgeable about the residents smoking unsupervised. She stated when she observes the residents smoking unsupervised, she redirects them and informs upper management. She stated the risk of the residents smoking unsupervised was that they could burn themselves or others. In an interview on 12/18/25 at 5:30AM with LVN-F; she stated she has been employed at the facility for 2-3 weeks. She stated she was not too familiar with the smoking policy because she works overnight, and the residents do not smoke on her shift. She stated she knows that the residents usually have assigned staff to supervise smoking on day and evening shifts but not overnight. She stated Resident # 11 was assigned to her hall and she usually gets up early in the morning to get coffee and she and other residents sit in the dining room area; she usually sees the resident on the way out. She stated the risk of residents smoking unsupervised could cause fire and if there is someone on oxygen then it would also be an issue. In an interview on 12/18/25 at 6:12 AM with CNA-C, she stated she worked night shift. She stated the residents had designated smoking times for day and evening shifts, but they did not have them for the night shifts. She stated there had never been a time that the residents had been smoking unsupervised during her shift. She stated if they noticed that residents were not in their rooms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some or in bed then they would go look for them. She stated residents were not allowed to keep cigarettes or lighters in their possession and that they were put in the lock box located on station 1. She stated the risk of the residents smoking unsupervised was they could set themselves on fire or set other things on fire. In an interview on 12/18/25 at 6:30AM with Administrator, he stated the smoking policy was that the residents are allowed to smoke in a designated area with supervised staff unless there was a visitor or family member with them. He stated staff were supposed to keep residents smoking supplies in a plastic container at the nurse's station. He stated the residents were not allowed to keep any of their supplies. He stated when residents go out to the store, they were asked if they have any smoking supplies and if so, they turn it in. He stated he was not aware that the residents were smoking unsupervised today. He stated he had been informed in the past that a resident had been smoking unsupervised. He stated he had a conversation with the resident, and the resident provided the cigarettes and lighter and it was stored at the nurse's station; residents name was not provided. He stated this was the only time that he had heard of residents smoking alone. He stated their smoking policy is when a resident is smoking unsupervised; they contact the RP, confiscate the items from the residents and if residents continue to not follow the smoking policy, then they would give the residents a 30-day discharge notice. He stated the risk of residents smoking unsupervised was the resident's dropping cigarettes on their clothes. He stated the residents had completed safe smoking assessments. In an interview on 12/18/25 at 2:38 PM with CNA-D, he stated he had witnessed Resident #12 and another resident (he could not remember the second residents name) smoking unsupervised a week or two ago and he notified the nurses. He stated he informed the nurse immediately-but he could not remember the name of the nurse he notified. He stated when he informed the nurse, they went outside and spoke with the residents and spoke with the residents, did a walk through, and collected smoking items that the residents had. He stated the risk of residents smoking unsupervised was that the residents could have a heart attack, choke, or burning themselves. Record review of Resident #10's smoking evaluation dated 09/21/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing, and follow the facility's policy on location and time of smoking. Record review of Resident #10's smoking assessment dated [DATE], revealed Resident #10 had cognitive loss, visual deficit, can light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of Resident #11's smoking evaluation dated 10/13/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing, and follow the facility's policy on location and time of smoking. Record review of Resident #11's smoking assessment dated [DATE], revealed Resident #11 had cognitive loss, visual deficit, dexterity problem, cannot light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of Resident #12's smoking evaluation dated 10/27/25, revealed supervision will be required for all Residents during designated smoking times. poor vision or blindness, balance problems while sitting or standing. Record review of Resident #12's smoking assessment dated [DATE], revealed Resident #12 had cognitive loss, visual deficit, dexterity problem, can light own cigarette, needed smoking apron and smoking supervision, and needed facility to store lighter and cigarettes. Record review of the facility Smoking policy dated March 2025 revealed: This facility has established and maintains safe resident smoking practices.12. Residents are allowed to smoke in the designated smoke area under the supervision of staff or a family member/visitor during visitation and smoking times, which are posted at the nurses station (s). 13. Residents and/or families are required to turn in all cigarette products and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675233 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 lighters to be stored in a container at the nurse station. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675233 If continuation sheet Page 8 of 8